What makes the good doctor outstanding?

Dr. Karen Djemal, who received a recent Outstanding Physician award, says when she has children they will be able to say they had a role model in her.

By JUDY SIEGEL-ITZKOVICH
Dr. Karen Djemal 311 (photo credit: Judy Siegel-Itzkovich)
Dr. Karen Djemal 311
(photo credit: Judy Siegel-Itzkovich)
What makes a good doctor? It sounds like an easy question, but the answer is far from simple. Of course, people prefer physicians who are empathetic; all-around experts in general practice or a specialty; willing to listen; familiar with the latest developments; who look at patients instead of having their noses in their computer screens; who have connections with other doctors; who are willing to make house calls in a real emergency; and are as eager to prevent disease as they are to treat it.
Very few physicians have all these traits, so patients are forced to look for one with the qualities they most need.
The Association of Medicine and Law in Israel – an organization that brings lawyers and physicians together to discuss issues on which the two fields meet – presents several Outstanding Physician prizes every year. For 2011, the awards were bestowed on veteran Hadassah University Medical Center obstetrician, gynecologist and fertility expert Prof. Neri Laufer; Sheba Medical Center orthopedist Dr. Hagai Amir and TEREM family physician Dr. Karen Djemal. The ceremony was held in Tel Aviv last month and attended by former Supreme Court justice Dalia Dorner (head of the Israel Press Council), association chairman and lawyer Ilan Bombach, and other dignitaries.
SOME PHYSICIANS may shudder to receive lawyer’s letters, fearing that a negligence lawsuit – common in this age of complicated medicine – has arrived. But doctors and lawyers have much to talk about amicably. The Patients Rights’ Law, passed in 1996, made it incumbent on physicians to be aware of their legal obligations to those they treat.
“Studies have shown that a relationship of honor, devotion and empathy by the doctor contributes to a dramatic decrease in the number of medical negligence lawsuits,” Dorner said. “In addition, relationships between doctor and patient that reflect mutual respect while allocating enough time for examination and consultation improve the transfer of information needed by the doctor and make it possible to improve the accuracy of diagnosis.”
The Jerusalem-born Laufer studied medicine at the Hebrew University-Hadassah Medical School, and focused on clinical research and fertility treatment, especially in-vitro fertilization. He devotes much effort to expanding women’s “window of fertility,” and is very involved in community activities, launching the “Health and Age” project to improve the quality of life for middle-aged and older women.
He also struggled to bring high-level medicine to women in the periphery, especially those who otherwise don’t have easy access to high-quality medical care. The Hadassah gynecologist/obstetrician also set up multidisciplinary clinics for women with special needs, such as adolescent girls, HIV carriers, women after menopause and rape victims. Many women recommended him for the honor because of his service as a doctor and human being and because he’s a modest person with wide interests who prefers to relate to patients without barriers.
Amir, an expert in orthopedic surgery and physical and rehabilitation medicine, also studied health system management and hypnosis. He worked as IDF chief orthopedist and adviser to the chief medical officer. The judges’ panel for the prize said Amir “treats everyone with respect, from a wounded soldier to a fellow officer or the cleaning worker in the hospital.... Financial reward is not his motive; it is only the good health of his patient.” Amir even goes to patients’ homes so the poor can get help without paying to reach the clinic.
The third winner of the citation is London-born Djemal, senior physician in the private TEREM network of urgent-care clinics established by the late Dr. David Applebaum, who preferred family medicine to emergency care, and for the past 15 years has been medical director of TEREM’s Family Care Clinic in Jerusalem’s Rehov Gedud Ha’ivri.
Djemal was a close colleague of Applebaum, who was murdered with his daughter Naava in a terror attack some eight years ago on the night before her scheduled wedding.
The Jerusalem Post interviewed Djemal to mark this year’s award.
The topic closest to Djemal’s heart – and for which she received the prize – is the importance of a close patient-doctor relationship, with emphasis on preventive medicine. In this context, patients are encouraged to take an active role in their healthcare, with checkups and proper lifestyle choices.
“There were no doctors in our family,” says Djemal.
“My father, who was born in England, had a clothing business on London’s East End, and was a self-made man. My mother, who was born in Belgium and was sent to London in 1939 to avoid the Nazis, was a housewife. I decided to be a physician at the age of 16.”
The small family included a sister who is now a social worker in Australia.
When Djemal went for an interview for medical school at the University of London’s St. Mary’s Hospital after completing a bachelor’s of science, she was asked if she had a role model. “I have none,” she said, “but when I have children, they will be able to say they had a role model.” She was accepted, and her four children – born to Dr.
Joe Djemal, now director of TEREM urgentcare clinics in Jerusalem and beyond – have a caring mother who doubles as a caring doctor. The couple came on aliya in 1988, with their first child, after specializing in family medicine; Karen worked for a short time at Jerusalem’s Shaare Zedek Medical Center and then – preferring community medicine – worked at Clalit Health Service’s neighborhood clinic in nearby Kiryat Moshe.
“I had thought of becoming a pediatrician or internal medicine specialist, but I didn’t like hospital medicine,” she reminisced. “You’re part of a team, which is good, but when the important senior physicians come into the wards for their rounds... the younger doctors don’t really understand. It wasn’t my milieu. I preferred personal medicine, disease prevention and health promotion.” In England, working in a hospital, she did late-night and weekend duty very frequently, sometimes 36 hours in a row. “We were too tired to think straight. Now, the hours are significantly shorter. Being a family physician in the community was much more compatible with home life. I was also looking for a personal relationship with patients.”
She left Clalit for Maccabi Health Services and worked for a while in Ma’aleh Adumim, but wanted to be in Jerusalem. Even though the private company TEREM, in which Joe was a partner with Applebaum, was established to provide expert urgent care and minimize emergency-room visits, it was willing to give the family medicine clinic a try.
“When we rented an apartment in Rehov Aza in Rehavia; we started with zero patients. Then Kupat Holim Meuhedet and Maccabi agreed to pay practitioners as independent physicians.” Gradually, news of the patient-friendly practice spread by word of mouth, and the clinic in nearby Rehov Gdud Ha’ivri was opened as its permanent home.
“I always tell people that in traditional Chinese medicine, the doctors got paid only if their patients become healthy. If they become or remain ill, the doctors would not be paid. A physician who waits for people to to get sick is missing the boat.
“Our philosophy is that our patients deserve the best medicine we can give. We are a group practice of family physicians with four women and three men, one studying a specialty plus nine or 10 other specialists who work in hospitals until mid-afternoon.
There are some doctors who receive only private patients and pay rent that keeps us going.”
But such a setup is not profitable. The health funds pay independent physicians between NIS 110 and NIS 130 per quarter per patient. If a patient turns up once in three months, clinics will make money, but if they come twice, they will break even and if they come a third time in the quarter, they will lose on the patient because of the time, says Djemal, whose group practice has some 5,000 patients registered per quarter (not all of them visit within the three months). Some are so pleased that they come from outside Jerusalem, including Tel Aviv or even the Golan Heights.
Djemal sees patients three times a week (the facility is open weekdays until 7 p.m.) rotating with colleagues on Friday mornings. The rest of the time, she performs administrative duties as director of the clinic. She also goes out on housecalls – an almost obsolete practice – when patients cannot reach her.
After our interview, she was on her way to the small apartment of a “92-year-old lady who has a foot ulcer that is not getting better because she doesn’t have money for fancy treatments” that are not included in the basket of health service. Djemal is trying to help her.
“WE AT Gdud Ha’ivri are very much a team. There have been no staff changes for a long time,” says Djemal, who from early on launched a “walk-in clinic” between 8 and 9 a.m. in which patients with emergencies can come without making an appointment. The clinic allows an average of 15 minutes for each patient visit – up to half an hour for new ones – compared to the average of seven minutes in ordinary health-fund clinics. “We don’t work by the clock,” she asserts.
Disease prevention and early diagnosis are a key to the practice.
“The patient comes to us with an agenda: ‘My knee hurts,’ or ‘I have an inflammation.’ But then we have an opportunity to check records and ask when they had their last Pap smear, mammogram, stool sample or cholesterol check. The clinic runs periodic workshops on diabetes, mental health, sexual health, nutrition (including presentations by a healthful foods chef, a doctor and a nutritionist) and more.
TEREM urgent care’s deputy director Dr. Nahum Kovalski, who is a computer whiz and introduced the next-morning “E-mail Blaster” system informing some 100 general practitioners of each patient’s emergency visits, melds well with Djemal’s services.
Gdud Ha’ivri patients are also routinely asked about family histories, which many ordinary doctors forget to record, and make sure that test results are examined and assessed. Djemal also sends a newsletter in Hebrew and English to all registered patients giving timely advice, such as on Pessah cleaning, risks of school vacations and the unpleasant topic of incontinence in women.
“We have a lot of satisfaction, and get a lot of appreciation. We are doing healing and prevention, and this is the core of medicine,” says Djemal, who jogs early mornings in the Katamon neighborhood before going to work, and thrills at seeing some of her patients doing the same.
“On average, Israelis enjoy better medical care than when I came on aliya. Patients are more educated, and doctors are not paternalistic; they partner with the patient in deciding what to do. It’s true that computers and bureaucratic tasks keep doctors busy, but physicians should still touch their patients to examine them, and not rely only on machines. Studies have shown that just this makes patients feel better.”
A medical school applicant “can have the highest grade, but lack the empathy a that someone else with lower grades feels,” concludes the winner of the Outstanding Physician award. “If wouldn’t have been accepted if there were the standards there are today.”